Provider Demographics
NPI:1962552950
Name:LULENSKI, GARY C (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:C
Last Name:LULENSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2500 NILES ROAD #5
Mailing Address - Street 2:
Mailing Address - City:ST JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085
Mailing Address - Country:US
Mailing Address - Phone:269-428-3442
Mailing Address - Fax:269-428-8062
Practice Address - Street 1:2500 NILES ROAD #5
Practice Address - Street 2:
Practice Address - City:ST JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085
Practice Address - Country:US
Practice Address - Phone:269-428-3442
Practice Address - Fax:269-428-8062
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI430103863207Y00000X, 207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101861013Medicaid
MI0401135182OtherBCBS
MI01135185042Medicare ID - Type Unspecified
MI101861013Medicaid